Medicare
Financial Resource Management and Healthcare Reimbursement
Introduction
Health Informatics Information Management(HIIM) professionals play a significant role in the quality management and the of coding management and reimbursement processes. The Centers for Medicare and Medicaid (CMS) acquaint with quality reporting systems to link financial rewards to the provision of quality healthcare. The legal and regulatory systems that impact work processes in HIIM and throughout healthcare organizations are unique in their mandates; healthcare organizations and providers should adhere to the law to prevent legal consequences. HIIM professionals working meticulously with the revenue cycle must report quality at all levels of the cycle. A systematic understanding of how the coding function influence the steps laterally to the continuum of the cycle of income will help decrease the risk of errors. Awareness of the work of quality improvement organizations and attention to recovery audit initiatives contribute to building a culture of compliance.
Body
First, two types of quality reporting systems are sponsored by the Centers for Medicare and Medicaid services namely; Physical Quality Reporting System(PQRS) and Value-Based Purchasing System(VBPS). PQRS is a voluntary health care program initiated by the CMS to provide incentives to healthcare professionals who take part in Medicare to submit detailed quality measures to CMS. The main aim of PQRS is to improve the quality of patient care through a collection of meaningful quality data (Centers for Medicare and Medicaid Services, 2016). PQRS is advantageous to the Eligible Professionals(EPs) in that it creates an opportunity them to assess the quality and ensure that they attend to their patients at the right time. Also, after reporting the PQRS measures and getting feedback from CMS, enables the Eps to compare their performance on a given metric with their peers. Alternatively, PQRS is disadvantageous as in that those who are not submitting significant data according to the PQRS are subject to negative adjustments on their payments as EPs (Centers for Medicare and Medicaid Services, 2016).
On the other hand, Value-Based Purchasing System(VBPS) is an effort by CMS which creates a linkage to Medicare’s payment system to a value-based program to improve the healthcare quality, involving the quality of health care in the inpatient hospital scenario (VanLare & Conway, 2012). Therefore, the facilities that are participating in VBPS are paid for inpatient critical care services grounded on the quality of health care, not just the amount of services delivered. Every hospital has a quality management method in place to be able to measure and control the care it provides to its patient. Shoemaker, 2011, suggests that VBPS package will promote measurable levels of quality and deliver specified measurement for the purpose of improvement. Also, since many healthcare facilities tend to negotiate with the commercial payers who primarily focus on price, implementation of VBPS will make these papers turn to Medicare in tying payment to quality as it can only reduce their payment if they do not. Therefore, it can help hospitals be self-assertive. The new VBPS program accelerates the developments of measurements that will result in more public scrutiny along with penalties on payments for poor performance (Shoemaker, 2011).
Healthcare Informatics Information management professionals’ primary role in quality management has been collecting data and reporting in a healthcare setting. Recently the HIIM professionals are more involved in the quality management(QM). They must possess the core competencies for QM and also partner with others to come up with reliable and valid measures of patient safety and quality.One of the core competencies of HIIM about QM states that they should possess data reviews skills and process engineering skills related to QM. (Spath, 2009).
Quality Improvement Organizations (QIO) is a category of healthcare quality experts, clinicians, and users organized to improve and enhance the quality of care delivered to the citizens. By law, the mission of QIO plan is to improve the effectiveness, economy, efficiency, and quality of services provided to CMS beneficiaries. A good example of QIO, Beneficiary, and Family Centered Care QIO, reviews the medical records every month to ensure that these records stay in which the facility made an update to the coding of the patient’s diagnoses and any other measures performed after the original submission of the coding to CMS. This coding illustrates how much Medicare pays the healthcare facility for care delivered. Also, the hospital may need to edit its coding for a variety of proper reasons, such as when the hospital identifies an error or omission. The BFCC-QIO are responsible for the confirmation of the change to the coding which accurately reflects the appropriate amount paid by CMS.
Some of the important government initiatives to improve the quality of care and healthcare reimbursement include the Medicare and Medicaid Patient and Program Protection Act of 1987(MMPPPA) and Medicare Prescription Drug Improvement and Modernization Act of 2003(MPDIMA). MMPPPA was a government’s initiative to provide penalties for criminal activities impacting Medicare and Medicaid (state health care reimbursable services). The act’s primary concerns prohibiting payment in return for referrals for or recommending the purchase of services and goods reimbursable under the state’s health care program (Chambers, Cangelosi, & Neumann, 2015 ). On the other hand, MMDIMA is important is that it the act advocates for the provision of subsidy for bigger pharmacies or healthcare facilities to discourage them from terminating private prescription coverage to the retired healthcare workers. Also, it prohibits the federal administration from negotiating discounts or markdowns with drug firms. Under these acts, two statutes concern Medicare: Stark II statute and the Anti-Kickback Statute.
First, Stark II law essentially forbids physicians from making transfers or referrals for certain healthcare services, in which the health care professional or a family member has a financial relationship. Therefore, Stark law is far much important as it is codified in the American Medical Association(AMA) Code of Ethics, and it should be adopted fully by physicians to save money. Otherwise, Ant-Kickback Statute provides that any person is it a patient or a physician is prohibited from paying or soliciting anything of value to induce referrals or generate federal healthcare program business. Anti-Kick Back statute is necessary as healthcare providers must not fall victim to such criminal activities which lead to heavy penalties of up to $50,000. Stark II and the MMPPPA slightly differ from the Anti-Kickback Statute in some ways. Both Stark II and MMPPPA only referrals are from a physician while the Anti-Kickback Statute’ s referrals are from anyone. Also, both Stark II and MMPPAA penalties are only civil in nature, such as, for a refund or overpayment obligation, Civil monetary penalties, False Claims Act liability. Alternatively, Anti-Kickback statute is both civil and criminal in nature. Criminal penalties can be 5-year incarceration or fines up to $25,000 per violation (Pope, 2016, p. 80). Lastly, both Stark II law and MMPPPA have mandatory exceptions while the Anti-Kickback statute has voluntary, safe harbors.
There are some other initiatives that the government has taken to improve the quality of healthcare. Such acts include the Sherman Act, Clayton Act, and the Federal Commissions Act. To begin with, the Sherman Act protects the healthcare providers, especially doctors, from being denied access to any hospital facility. According to the law, it is assumed that the other healthcare providers have come together like a monopoly to outwit the one doctor. Therefore, Sherman Act is essential for healthcare providers regarding access to facilities. Additionally, the Clayton Act specifies that in the healthcare field it is prohibited for any hospital managing company to purchase hospitals in one geographical location, as it can create a monopoly, it prohibits collective schemes between physicians or hospitals. Lastly, the Federal Trade Commission Act majorly protects consumers in health care competitive markets since it is essential for improved care indicators, cost-contained, and encourage innovation. Also, the Act helps healthcare providers by giving them guidance to help them comply to ensure that customers in the health care markets are comfortable and that the nation’s antitrust laws are adhered to.
To keep the healthcare facility’s financially solvent the HIIM are the most crucial in the management of the revenue cycle in any healthcare setting. Below is a table showing steps in revenue cycle and the role played HIIM at each stage.
Revenue Cycle: Step-by-Step Table
| Step | Activity | Role of HIIM staff |
| Registration | Obtaining patients information such as medical insurance information | Collection and organization of data. Data entry skills. |
| Eligibility and Authorization of patients. | Verification and prior authorization of patients. | The HIIM will search the database to establish and verify the authenticity of the data provided and issues an authorization |
| Payments and Electronic Claim Submittals | Cash Collection and Updating on the Electronic Records. Opening patients’ account for revenue collection. | The HIIM must be conversant with the conventional Electronic Health Records systems(EHRs). Have the accounting knowledge and is responsible for tracking any payments. |
| Payment Posting and Payments Deductions from any Insurance Company or Medicare. Patients Collection, Physician Reviews | Accounting methods | The HIIM staff are responsible for fetching valuable information concerning the patient and computing the amount required for the patient to pay. |
| Management Reporting | Reporting | The HIIM personnel integrates the information on payments in the revenue cycle to create a comprehensive management report |
Therefore, as mentioned earlier, the HIIM are required to possess core competencies that are essential for Quality Management.
Conclusion
Conclusively, according to the American Medical Association, 2016, Transactions are any electronic
exchange of information between two or more parties for a specified purpose. For
example, a healthcare professional can request payment through claiming an
insurance policy. Health Insurance Portability and Accountability Act (HIPAA)
has adopted standards for transacting electronic data interchange of the
administrative healthcare data. Therefore, covered entities must adhere to the
format and content required for each transaction. Under the HIPAA, the
Department of Health and Human services have specific codes sets for diagnoses
and procedures to be used for transactions. Therefore, the coders are required
to comply with the requirements if HIPAA to carry out any legal transactions.
References
American Medical Association. (2016, 7 15). Transaction and Code of Standards. Retrieved from American Medical Association: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards.page?
Centers for Medicare and Medicaid Services. (2016, 5 26). Physician quality reporting system. Retrieved 7 14, 2016, from Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqri
Chambers, J. D., Cangelosi, M. J., & Neumann, P. J. (2015 ). Medicare’s Use of Cost-Effectiveness Analysis for Prevention (but not for treatment). Health Policy, 119(2), 156-163.
Pope, J. E. (2016). Referral Networks. In J. E. Pope, Integrating Pain Treatment into Your Spine Practice (pp. 77-83). Springer International Publishing.
Shoemaker, P. (2011). What Value-Based Purchasing means to your Hospital:. Healthcare Financial Management, 65(8), 60-69.
Spath, P. (2009). Role of HIM Professionals in Quality Management. Perspectives in Health Information Management, 6. American Health Information Management Association.
VanLare, J. M., & Conway, P. H. (2012). Value-Based Purchasing—National Programs to Move from Volume to Value. New England Journal of Medicine, 367(4), 292-295.